Preoperative Overestimation of Disease Extent and Discordance-Driven Mastectomy: A Retrospective Review of 245 Cases.

Authors

Hadas Kadar Sfarad, Cheng-Bang Chen, Yujie Wang, Mehmet Akcin, Heidi Santa Cruz, Karishma Chapalamadugu, Emily McFarlane, Eli Avisar

Published in

Annals of surgical oncology. Jul 17, 2026. Epub Jul 17, 2026.

Abstract

Preoperative mammography and magnetic resonance imaging (MRI) guide surgical planning in breast cancer but may misestimate disease extent. We quantified imaging-pathology discordance among patients undergoing mastectomy and estimated the discordance-driven mastectomy rate (DDMR), defined as imaging-extensive disease with localized final pathology, as a measure of discordance.
We retrospectively reviewed 245 consecutive mastectomy cases (2018-2019) at a tertiary academic center; 236 had usable postoperative pathology and were analyzed. Preoperative imaging (mammography and/or MRI) was classified as localized versus extensive using predefined extent-indicating features and/or maximum size > 5 cm. Final pathology was similarly classified using size and multifocality/multicentricity as the reference standard. Concordance categories were concordant-localized, concordant-extensive, imaging overestimation, and imaging underestimation. The primary outcome was any discordance; the key clinical outcome was DDMR. Decision drivers were abstracted from the medical record when available.
Overall discordance occurred in 119/236 (50.4%) cases and was predominantly imaging due to overestimation (113/236, 47.9%; 95% CI 41.4-54.5); underestimation was uncommon (6/236, 2.5%). DDMR events occurred only when at least one modality had extent-indicating features and were common with mammography-only (44/53, 83.0%), MRI-only (30/43, 69.8%), or both (39/62, 62.9%). DDMR rates were similar across mastectomy subtypes and by neoadjuvant chemotherapy receipt. Among DDMR cases, surgeon-only requests were most frequent (71/113, 62.8%) versus patient-only requests (31/113, 27.4%; p < 0.001). Agreement between imaging and pathology was low (MRI κ = 0.241; mammography κ = 0.123).
Among a cohort of patients undergoing mastectomy, imaging-pathology discordance was common and predominantly reflected overestimation. These findings highlight the importance of cautious interpretation of imaging-defined extent within clinical decision-making.

PMID:
42467150
Bibliographic data and abstract were imported from PubMed on 17 Jul 2026.

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